Provider Demographics
NPI:1245759380
Name:VAIRA, SHANDA DAWN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANDA
Middle Name:DAWN
Last Name:VAIRA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SHANDA
Other - Middle Name:DAWN
Other - Last Name:CROWDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:3275 PONY TRACKS DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-1416
Mailing Address - Country:US
Mailing Address - Phone:970-219-6883
Mailing Address - Fax:
Practice Address - Street 1:3275 PONY TRACKS DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-1416
Practice Address - Country:US
Practice Address - Phone:970-219-6883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-10
Last Update Date:2017-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004629103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist